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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 05/28/2021
Date Signed: 05/28/2021 12:45:41 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2021 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210204085536
FACILITY NAME:BROOKDALE NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 86DATE:
05/28/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kimberly HumphreyTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff does not have appropriate medication training
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit with Kimberly Humphrey, Executive Director for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation staff does not have appropriate medication training. Operations Specialist provided training records for staff through 2020. 11 records reviewed indicate staff in Med Tech positions do not have required hours of medication training. Interviews confirm staff have not been provided training. Based on LPAs observations, interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.


(See LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20210204085536
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BROOKDALE NAPA
FACILITY NUMBER: 286800493
VISIT DATE: 05/28/2021
NARRATIVE
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California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given to the Administrator. Exit interview was conducted and a copy of this report was emailed to the Administrator for signature.

(See LIC 9099-D)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/04/2021 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210204085536

FACILITY NAME:BROOKDALE NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 86DATE:
05/28/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kimberly HumphreyTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not meet the needs of resident in care
Resident's personal items have gone missing
Medications accessible to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit with Kimberly Humphrey, Executive Director for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation facility staff did not meet the needs of resident in care. Complainant alleges that R1 was being starved leading to their demise. R1’s Personal Service Plan dated 8/31/2020 indicated “R1 had changed their interest in meals, sometimes saying does not have appetite, but favorite meal is breakfast. 9/22/2019 R1 requires convincing to eat meals at times and continues on a texture modified diet, R1’s weight is stable.” Multiple interviews reveal it became more difficult for R1 to eat as part of their disease process. Interviews also confirmed staff offered R1 food multiple times a day. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.
(See LIC 9099-C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20210204085536
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BROOKDALE NAPA
FACILITY NUMBER: 286800493
VISIT DATE: 05/28/2021
NARRATIVE
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There is an allegation resident's personal items have gone missing. LPA received facility’s theft and loss policy. Although complainant alleges items went missing for R2 or R3, Executive Director confirmed on 5/20/2021 there were no records to indicate R2 or R3 had lost any items. LPA did not receive any corroborating statements, that resident’s personal items had gone missing. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

There is an allegation medications accessible to residents in care. Although complainant alleges medications were accessible to residents in care, multiple interviews with staff and residents indicate medication cart is in hallway but medication cart and medications are secured. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20210204085536
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BROOKDALE NAPA
FACILITY NUMBER: 286800493
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2021
Section Cited
CCR
1569.69(b)
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 (1569.69(b) Each employee…continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met as evidenced by:

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Facility to ensure required medication training is completed. Facility agrees to develop a plan to bring Med Tech’s training current per Health and Safety guidelines by POC date of 6/1/2021.
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Based on LPA observation, interview and record review staff did not have required mediation training. This is an immediate risk to the Health, Safety and Personal rights of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5